What is the best treatment for ear pressure?

Treatment of Ear Pressure

For ear pressure without infection, use oral decongestants like pseudoephedrine (30 mg every 4-6 hours for adults) to relieve Eustachian tube dysfunction, combined with analgesics (ibuprofen 10 mg/kg or acetaminophen) for symptomatic relief. 1, 2

Initial Assessment and Cause Identification

The approach to ear pressure depends critically on identifying the underlying cause:

• Examine the tympanic membrane to rule out middle ear effusion, acute otitis media, tympanic membrane perforation, or cerumen impaction 3
• Assess for modifying factors including recent upper respiratory infection, recent air travel or diving, presence of fever, ear drainage, or hearing loss 4
• Document laterality (unilateral vs bilateral) and whether symptoms are constant or intermittent 3

Primary Treatment Algorithm

For Eustachian Tube Dysfunction (Most Common Cause)

Oral decongestants are the first-line treatment for ear pressure related to Eustachian tube dysfunction:

• Pseudoephedrine 30 mg orally every 4-6 hours as needed for adults 1
• This reduces mucosal edema and improves Eustachian tube patency
• Avoid in patients with hypertension, cardiac disease, or hyperthyroidism 1

Pain Management

Analgesics should be provided based on pain severity:

• Ibuprofen 10 mg/kg orally every 6-8 hours is superior to placebo for ear pain relief (NNTB = 6) 2, 5
• Acetaminophen 15 mg/kg orally every 4-6 hours is also effective (NNTB = 7) 2, 5
• Low quality evidence shows both are more effective than placebo at 48 hours, with 7% still experiencing pain with ibuprofen versus 25% with placebo 2, 5

Topical Anesthetic Drops

For moderate to severe ear pain with intact tympanic membrane:

• Antipyrine-benzocaine otic drops (Auralgan) provide additional relief within 30 minutes when combined with oral analgesics 6
• Instill drops into the external auditory canal of affected ear(s) 6
• Only use if tympanic membrane is intact - never use with perforation or tympanostomy tubes 4

When Antibiotics Are NOT Needed

Do not prescribe systemic antibiotics for uncomplicated ear pressure alone unless there is:

• Extension of infection outside the ear canal 4
• Visible purulent drainage indicating acute otitis media 4
• Fever >101.5°F with signs of bacterial infection 7
• Immunocompromised state or diabetes 4

The American Academy of Otolaryngology strongly recommends against systemic antimicrobials as initial therapy for uncomplicated ear conditions without these modifying factors 4.

Special Circumstances

If Tympanostomy Tubes Are Present

• Topical antibiotic drops (ofloxacin or ciprofloxacin-dexamethasone) are preferred over oral antibiotics for tube-related infections 4
• Place drops in ear canal twice daily for up to 10 days 4
• Pump the tragus after instillation to help drops enter the tube 4

If Ménière's Disease Is Suspected

For ear pressure with vertigo, hearing loss, and tinnitus:

• Consider betahistine (where available), though evidence is mixed 4
• Diuretics (hydrochlorothiazide, acetazolamide) may help with endolymphatic hydrops 8
• Refer to otolaryngology for intratympanic steroid therapy if symptoms persist 4

Common Pitfalls to Avoid

• Never use cotton swabs, Play-Doh, or silly putty as earplugs - these can become trapped and require surgical removal 4
• Avoid topical drops with perforated tympanic membrane unless specifically indicated 4
• Do not prescribe oral antibiotics reflexively - observation with pain control is appropriate for many cases 7
• Positive pressure devices (Meniett) are NOT recommended based on recent systematic reviews showing no benefit over placebo 4

When to Refer to Otolaryngology

Refer if:

• Symptoms persist beyond 7 days despite treatment 4
• Hearing loss accompanies ear pressure 4
• Recurrent episodes occur (≥3 in 6 months) 4
• Unilateral symptoms persist despite conservative management 3
• Suspected complications like perichondritis or abscess formation 4